Beruflich Dokumente
Kultur Dokumente
Michael L. Fiore, MD Fellow in Critical Care Medicine Mary W. Lieh-Lai, MD, Director, ICU and Fellowship Program Division of Critical Care Medicine Childrens Hospital of Michigan/Wayne State University
REVISION OF DEFINITIONS
1988: four-point lung injury score Level of PEEP PaO2 / FiO2 ratio Static lung compliance Degree of chest infiltrates 1994: consensus conference simplified the definition
Childrens Hospital of Michigan
A.K.A.
Adult Respiratory Distress Syndrome Da Nang Lung Transfusion Lung Post Perfusion Lung Shock Lung Traumatic Wet Lung
HISTORICAL PERSPECTIVES
Described by William Osler in the 1800s Ashbaugh, Bigelow and Petty, Lancet 1967 12 patients pathology similar to hyaline membrane disease in neonates ARDS is also observed in children New criteria and definition
Childrens Hospital of Michigan
ORIGINAL DEFINITION
Acute respiratory distress Cyanosis refractory to oxygen therapy Decreased lung compliance Diffuse infiltrates on chest radiograph
Difficulties: lacks specific criteria controversy over incidence and mortality
Childrens Hospital of Michigan
1994 CONSENSUS
Acute onset may follow catastrophic event Bilateral infiltrates on chest radiograph PAWP < 18 mm Hg Two categories: Acute Lung Injury - PaO2/FiO2 ratio < 300 ARDS - PaO2/FiO2 ratio < 200
Childrens Hospital of Michigan
EPIDEMIOLOGY
Earlier numbers inadequate (vague definition) Using 1994 criteria: 17.9/100,000 for acute lung injury 13.5/100,000 for ARDS Current epidemiologic study underway In children: approximately 1% of all PICU admissions
INCITING FACTORS
Shock Aspiration of gastric contents Trauma Infections Inhalation of toxic gases and fumes Drugs and poisons Miscellaneous
Childrens Hospital of Michigan
STAGES
Acute, exudative phase rapid onset of respiratory failure after trigger diffuse alveolar damage with inflammatory cell infiltration hyaline membrane formation capillary injury protein-rich edema fluid in alveoli disruption of alveolar epithelium
Childrens Hospital of Michigan
STAGES
Subacute, Proliferative phase: persistent hypoxemia development of hypercarbia fibrosing alveolitis further decrease in pulmonary compliance pulmonary hypertension
STAGES
Chronic phase obliteration of alveolar and bronchiolar spaces and pulmonary capillaries
Recovery phase gradual resolution of hypoxemia improved lung compliance resolution of radiographic abnormalities
Childrens Hospital of Michigan
MORTALITY
40-60% Deaths due to: multi-organ failure sepsis Mortality may be decreasing in recent years better ventilatory strategies earlier diagnosis and treatment
Childrens Hospital of Michigan
PATHOGENESIS
Inciting event Inflammatory mediators Damage to microvascular endothelium Damage to alveolar epithelium Increased alveolar permeability results in alveolar edema fluid accumulation
Childrens Hospital of Michigan
NORMAL ALVEOLUS
Type I cell Alveolar macrophage Endothelial Cell RBCs Type II cell Capillary
PATHOGENESIS
Target organ injury from hosts inflammatory response and uncontrolled liberation of inflammatory mediators Localized manifestation of SIRS Neutrophils and macrophages play major roles Complement activation Cytokines: TNF-a, IL-1b, IL-6 Platelet activation factor Eicosanoids: prostacyclin, leukotrienes, thromboxane Free radicals Nitric oxide
Childrens Hospital of Michigan
PATHOPHYSIOLOGY
Abnormalities of gas exchange Oxygen delivery and consumption Cardiopulmonary interactions Multiple organ involvement
OXYGEN EXTRACTION
Cell
O2
Arterial Inflow (Q)
O2 O2 O2 O2
capillary
O2 O2 O2
OXYGEN DELIVERY
DO2 = Q X CaO2 DO2 = Q X (1.34 X Hb X SaO2) X 10 Q = cardiac output CaO2 = arterial oxygen content Normal DO2: 520-570 ml/min/m2 Oxygen extraction ratio = (SaO2-SvO2/SaO2) X 100 Normal O2ER = 20-30%
Childrens Hospital of Michigan
HEMODYNAMIC SUPPORT
Max O2 extraction Max O2 extraction
VO2
Critical DO2
VO2
Critical DO2
DO2
DO2
Normal
VO2 = DO2 X O2ER
Childrens Hospital of Michigan
Septic Shock/ARDS
Abnormal Flow Dependency
CARDIOPULMONARY INTERACTIONS
A = Pulmonary hypertension resulting in increased RV afterload B = Application of high PEEP resulting in decreased preload A+B = Decreased cardiac output
RESPIRATORY SUPPORT
Conventional mechanical ventilation Newer modalities: High frequency ventilation ECMO Innovative strategies Nitric oxide Liquid ventilation Exogenous surfactant
Childrens Hospital of Michigan
MANAGEMENT
Monitoring:
MANAGEMENT
Optimize VO2/DO2 relationship DO2 hemoglobin mechanical ventilation oxygen/PEEP VO2 preload afterload contractility
Childrens Hospital of Michigan
CONVENTIONAL VENTILATION
Oxygen PEEP Inverse I:E ratio Lower tidal volume Ventilation in prone position
RESPIRATORY SUPPORT
Goal: maintain sufficient oxygenation and ventilation, minimize complications of ventilatory management Improve oxygenation: PEEP, MAP, Ti, O2 Improve ventilation: change in pressure
PEEP - Benefits
Increases transpulmonary distending pressure Displaces edema fluid into interstitium Decreases atelectasis Decrease in right to left shunt Improved compliance Improved oxygenation
Predicting outcome in children with severe acute respiratory failure treated with high-frequency ventilation
Sarnaik AP, Meert KL, Pappas MD, Simpson PM, Lieh-Lai MW, Heidemann SM Crit Care Med 1996; 24:1396-1402
SUMMARY OF RESULTS
Significant improvement in pH, PaCO2, PaO2 and PaO2/FiO2 occurred within 6 hours after institution of HFV The improvement in gas exchange was sustained Survivors showed a decrease in OI and increase in PaO2/FiO2 twenty four hours after instituting HFV while non-survivors did not Pre-HFV OI > 20 and failure to decrease OI by > 20% at six hours predicted death with 88% (7/8) sensitivity and 83% (19/23) specificity, with an odds ratio of 33 (p= .0036, 95% confidence interval 3-365)
STUDY CONCLUSIONS
In patients with potentially reversible underlying diseases resulting in severe acute respiratory failure that is unresponsive to conventional ventilation, high frequency ventilation improves gas exchange in a rapid and sustained fashion. The magnitude of impaired oxygenation and its improvement after high frequency ventilation can predict outcome within 6 hours.
Childrens Hospital of Michigan
STUDY CONCLUSION
In patients with acute lung injury and the acute respiratory distress syndrome, mechanical ventilation with a lower tidal volume than is traditionally used results in decreased mortality and increases the number of days without ventilator use
Prone Position
Improved gas exchange More uniform alveolar ventilation Recruitment of atelectasis in dorsal regions Improved postural drainage Redistribution of perfusion away from edematous, dependent regions
Prone Position
Nakos G et al. Am J Respir Crit Care Med 2000;161:360-68 Observational study of 39 patients with ARDS in different stages Improved oxygenation in prone (PaO2/FiO2 18934 prone vs. 8314 supine) after 6 hours No improvement in patients with late ARDS or pulmonary fibrosis
Childrens Hospital of Michigan
Prone Position
NEJM 2001;345:568-73 Prone-Supine Study Group Multicenter randomized clinical trial 304 adult patients prospectively randomized to 10 days of supine vs. prone ventilation 6 hours/day Improved oxygenation in prone position No improvement in survival
Childrens Hospital of Michigan
Exogenous Surfactant
Success with infants with neonatal RDS Exosurf ARDS Sepsis Study. Anzueto et al. NEJM 1996;334:1417-21 Randomized control trial Multicenter study of 725 patients with sepsis induced ARDS No significant difference in oxygenation, duration of mechanical ventilation, hospital stay, or survival
Childrens Hospital of Michigan
Exogenous Surfactant
Aerosol delivery system only 4.5% of radiolabeled surfactant reached lungs Only reaches well ventilated, less severe areas New approaches to delivery are under study, including tracheal instillation and bronchoalveolar lavage
Corticosteroids
Acute Phase Trials
Bernard GR et al. NEJM 1987;317:1565-70 99 patients prospectively randomized Methylprednisolone (30mg/kg q6h x 4) vs. placebo No differences in oxygenation, chest radiograph, infectious complications, or mortality
Corticosteroids
Fibroproliferative Stage
Meduri GU et al. JAMA 1998;280:159-65 24 patients with severe ARDS and failure to improve by day 7 of treatment Placebo vs. methylprednisolone 2mg/kg/day for 32 days Steroid group showed improvement in lung injury score, improved oxygenation, reduced mortality No significant difference in infection rate
Childrens Hospital of Michigan
PROGNOSIS
Underlying medical condition Presence of multiorgan failure Severity of illness
We are constantly misled by the ease with which our minds fall into the ruts of one or two experiences.
Sir William Osler